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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600809
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:35:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230901133006
FACILITY NAME:JANIE'S HOMEFACILITY NUMBER:
415600809
ADMINISTRATOR:MURPHY, MAY MITZIFACILITY TYPE:
740
ADDRESS:197 FLYING CLOUD ISLETELEPHONE:
(650) 349-2943
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:6CENSUS: 4DATE:
10/19/2023
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Assistant Administrator, Shalimar LardizabalTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility is unkempt
Facility did not post required information at the facility
Alterations to existing building
INVESTIGATION FINDINGS:
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On 10/19/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the investigation findings. LPA met with assistant administrator and explained the purpose of the visit.

Regarding to allegation of facility is unkempt, the reporting party stated that facility was under construction and appeared to be cluttered, dusty, items in the main living room looked disorganized and there was plastic sheet hanging over one of the doors.

As part of the investigation, LPA conducted a facility tour and interviewed assistant administrator.

During the visit on September 6, 2023, as LPA entered the facility, LPA observed 2 construction workers on-site, and both of them were working around the kitchen area. One of them was working in the kitchen while the other one was painting behind an area next to the kitchen that was tapped off by a big piece of plastic from the ceiling to the floor.

During the facility tour, LPA observed construction supplies on the kitchen floor area such as a paint buckle, a can of paint, paint supplies, tape, boxes of opened and opened wood, maintenance tools, plastic paper, etc.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 14-AS-20230901133006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JANIE'S HOME
FACILITY NUMBER: 415600809
VISIT DATE: 10/19/2023
NARRATIVE
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In addition, LPA observed living room table was cluttered with kitchen appliances such as a Ninja blender, a toaster over, plates, a big bottle of supplement, etc.

Furthermore, facility created an outdoor kitchen as the kitchen was temporarily out of service due to construction, and in the outdoor kitchen, LPA observed cooking spices were placed on the floor, cleaned and dirty bottles/containers were co-mingled, bottles on the floor with a lot of brown and white spots, kitchen utensils on the floor and white powder on the table.

LPA interviewed assistant administrator who stated that facility started the renovation earlier this year and acknowledged that the facility was cluttered, and unkempt as a result from the renovation.

After the investigation, this allegation is deemed to be substantiated.

Regarding to facility did not post required information at the facility, the reporting party stated that facility failed to post Ombudsman poster.

During the facility tour on 9/6/2023, LPA did not observed any required posters at the facility including but not limiting to the Ombudsman poster, the Licensing Complaint Poster, Residents Rights, etc.

According to the assistant administrator, all the posters were removed from the wall due to the construction.

After the investigation, this allegation is substantiated.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 14-AS-20230901133006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JANIE'S HOME
FACILITY NUMBER: 415600809
VISIT DATE: 10/19/2023
NARRATIVE
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Regarding to alterations to existing building, the reporting party reported that facility was under construction, there was increase in noise due to the construction and resident #1 (R1) moved out of the facility due to the noise level from the construction.

As part of the investigation, LPA interviewed assistant administrator, resident, responsible parties, and contacted the local code enforcement.

According to the assistant administrator, facility has obtained the proper building permit for the construction and building inspection is on-going as the work is still in progress.

LPA interviewed resident #2 (R2) who stated that the administrator made a causal announcement one day in the dining room during dinner about the construction but they were not formally informed. In addition, R2 stated that the noise level from the construction was very loud in the beginning but has since improved as the construction is almost ending. Furthermore, R2 stated that R1 moved out of the facility because it was too noise.

Based on the documents provided by the facility, facility has obtained a building permit for the renovation and LPA also contacted Foster City Code Enforcement and they confirmed that facility has obtained building permit for the renovation and inspections were conducted upon the completion of each section. However, LPA observed a room in the garage and it was not part of the facility sketch. According to the assistant administrator, the room was build a few years ago for the assistant administrator and the assistant administrator was unsure if the administrator/licensee went through the proper procedures to build the room

LPA interviewed the administrator/licensee who acknowledged that the assistant administrator's room in the garage was not part of the facility sketch, it was build a few years ago and the facility did not get a permit to do that.

LPA interviewed family members regarding to the construction and all of them reported that they were not formally notified of the construction, they either learned about it from their loved ones or they were told by facility staff during their visits.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 14-AS-20230901133006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JANIE'S HOME
FACILITY NUMBER: 415600809
VISIT DATE: 10/19/2023
NARRATIVE
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After the investigation, this allegation is substantiated as the facility obtained proper permits for the kitchen and the family room renovation, however, the facility failed to obtain a permit to build a room in the garage. In addition, the administrator failed to provide proper notification to residents, their responsible parties of the construction and CCL. Furthermore, residents were not kept comfortable as the facility was too noisy due to the construction.

During today's visit, there are 2 facility staff (S1 and S2) and assistant administrator present. LPA requested for personnel files and assistant administrator reported that facility does not have personnel files for S1 and S2.

In addition, S1 did not have a criminal record clearance and was not associated with the facility. According to the administrator and the assistant administrator, S1 has been working at the facility for couple of months now (since 9/1/2023) and the facility is in the process of obtaining the documents. This observation will be cited under LIC 809 and LIC809 D- case management.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 14-AS-20230901133006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JANIE'S HOME
FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87405(d)(2)
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87405 Administrator - Qualifications and Duties..(d) The administrator shall have the qualifications..(2) Knowledge of and ability to conform to the applicable laws, rules and regulations...This requirement is not met as evidenced by
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The administrator will reviewed all the regulations that are cited today and will provide a signed/dated statement of acknowledgement after the review.

The administrator will submit a copy
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administrator build a room in the garage without going through the proper procedure(s), administrator failed to provide notification to residents, CCL, and responsible parties of the construction, and failed to ensure the facility is clean, safe, sanitary and in good repair at all times which poses an immediately health risk to residents in care.
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of the signed/dated acknowledgement to CCL by 10/20/2023.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 14-AS-20230901133006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JANIE'S HOME
FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87305(a)
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87305 Alterations to Existing Building or New Facilities... (a)Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by facility build a room
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During today's visit, administrator/licensee provided a copy of the permit, however, inspection is incomplete as the administrator has not paid the fee.
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in the garage without a proper building permit which poses an immediate health risks to residents in care.
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Licensee/administrator shall submit a plan in writing to ensure compliance Licensee/administrator will provide a copy of the plan to CCL by 10/20/2023.
Type A
10/20/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities shall have all of the following personal rights:..(2) To be accorded safe, healthful and comfortable accommodations..
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The administrator will develop a plan to ensure residents are safe, and comfortable at all times and will submit a copy of the plan to CCL by 10/20/2023.
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This requirement is not met as evidenced by residents and responsible parties reported that the facility was very noise during the construction and resulted one resident moved out which poses an immediate health risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 14-AS-20230901133006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JANIE'S HOME
FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation..a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not as evidenced by facility is under construction, facility appeared cluttered with construction supplies on the floor, kitchen supplies and spices on the
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The administrator will develop a plan to ensure the facility is clean, safe, and sanitary and in good repair at all times.
The administrator will provide a copy of the plan to CCL by 10/20/2023
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floor, and kitchen appliances in the living room table. In addition, in the temporary kitchen, LPA cooking spices on the floor, cleaned and dirty bottles/containers were co-mingled on the floor, white unidentified powers on powder on the table, and kitchen utensils on the floor which poses an immediate health risk to resident in care.
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Type B
10/26/2023
Section Cited
CCR
87468.1(a)(4)
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87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities.. shall have all of the following personal rights:4) To be informed by the licensee of the provisions of law regarding complaints and of procedures for confidentially registering
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The administrator will ensure all the required posters are posted and will send a photo to CCL by 10/26/2023 to proof that all the required posters are posted.
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complaints,.. this requirement is not met as evidenced by facility removed all the required posters due to the construction which poses a potential health risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7